Outcomes of Health Systems :

Towards the development of

indicators of amenable mortality

Work: Juan G. Gay

Presentation: Valérie Paris

OECD

October 9, 2009

Objectives of the project

• Explore the potential of “Amenable Mortality” to serve as an

indicator of health care systems outcomes in cross-country

comparisons.

• Assess the feasibility of inclusion of amenable mortality rates in

OECD Health data

Outcome indicators to measure health

systems performance in OECD statistics

• Health status:

– Mortality: Life expectancy; Mortality rates by cause; Potential years of

life lost by cause; maternal and infant mortality

– Morbidity: perceived health status, low-weight births, dental health,

incidence of some communicable diseases, Incidence of some cancers,

and absence from work

• Life styles and behaviours (that health systems may seek to influence): food

consumption, alcohol and tobacco consumption, body weight.

• Quality of care (Health care quality indicator project):

– Disease specific survival rates, Avoidable hospital admissions,

– Patient safety, patient satisfaction and system’s responsiveness (in

development)

• Equity in access to health care or in health status (?)

– see De Looper and Lafortune, OECD 2009

Health status:

what can be attributed to health systems?

• Current indicators:

– Either lack of specificity (e.g. Life expectancy can be influenced

by many other factors than health systems interventions)

– Or are too narrow to get a “global picture” of health systems

performance (e.g. mortality for a specific cause or HCQ

Indicators)

• Mortality “amenable to health care” could serve as an indicator for

global performance in improving health status

The concept of “Mortality amenable

to health care/systems”

• “Amenable deaths” = “deaths that should not occur in the presence of timely and effective health care”

• “Amenable mortality” is measured by:

– Age-standardised mortality rates

– For selected causes of death: “Conditions for which effective clinical interventions exist [that should prevent premature deaths]” (Tobias and Yen 2009)

– In people under 75 years old (general age limit)

• With some adaptations for some diseases:

– E.g. only half of deaths due to ischemic heard diseases are considered to be amenable to health care

– Age limits vary for some causes to take into account the fact that health systems cannot be held responsible for deaths above or below a certain age in certain disease categories

• Criteria for inclusion are “evidence-based”

Amenable / avoidable?

• Terms sometimes used as synonyms in the literature

• Eurostat – Atlas of mortality (2009)

– “Avoidable’ is loosely defined as important causes of death

which could be avoided by changing lifestyles or health policies”.

– Includes for instance deaths from road accident, suicides

– Age limit set at 65.

• The difference between the two concepts pertains to the

“boundaries of health systems”

– e.g. Prevent fatal home injuries or road accidents is not always

in the scope of MoH activities

– E.g. Suicides are not included in amenable mortality though

prevention of suicide is generally included in formulated health

policy objectives

• Usually, “avoidable mortality” includes more causes of death and a

unique age limit.

Methodology and dataData

• Mortality databases from the WHO Statistical Information System (WHOSIS).

• From 1996 to 2006 (or last available year 2004-2005)

• Population structure: OECD population structure 1980.

• Lists of causes published by Nolte & McKee (2008) and Tobias & Yeh (2009)

• Limitations:

– Switzerland and Turkey excluded because of data limitations

– Minor modifications to the original Tobias & Yeh list were done to fit the

particular grouping of codes used in the WHO database (only in ICD9

codes):

• Exclusion of deaths from Thyroid Cancer because they are integrated

in a much larger category in the WHO database.

• Asthma included in the Chronic Obstructive Pulmonary Diseases

category (all ages <75 included).

Method

• Standardize Mortality Rates (SMR) over 100,000 people for specific causes of

death in specific age groups (<75 years).

Analyse

Analyse

• Level and trend in amenable mortality

• Analysis by gender

• Comparison of results obtained from the two lists of “amenable causes”

• Disaggregated analysis according to partition proposed by Murray & Lopez (1996):

– Transmittable, maternal and perinatal causes of deaths.

– Non transmittable diseases.

Nolte & McKee (2008) and Tobias & Yeh (2009)

Causes of deaths Nolte & McKee (2008) Tobias & Yeh (2009)

Infectious diseases Tuberculosis

Intestinal Infections (other than typhoid,

diphtheria) <14

Typhoid, diphtheria, tetanus, septicaemia,

poliomyelitis, osteomyelitis

Whooping cough & measles <14

Measles – 1-14

Tuberculosis,

Selective invasive bacterial infections

(incl. malaria, meningitis, infections of the

skin)

Neoplasms Colorectal cancer,

Malignant neoplasm of skin

Breast cancer

Cervical cancer and uterine cancer (<45)

Neoplasm of the testis

Hodgkin’s disease,

Leukaemia < 45

Colorectal cancer,

Melanoma of skin, nonmelanotic skin

cancer, Breast cancer

Cervical cancer and uterine cancer

Bladder cancer

Thyroid cancer

Hodgkin’s disease,

Leukaemia < 45

Benign tumours

Endocrine,

nutritional and

metabolic diseases

Thyroid disorders

Diabetes mellitus < 50

Thyroid disorders

Diabetes (type 2) - 50% of deaths

Diseases of the

nervous systemEpilepsy Epilepsy

Nolte & McKee (2008) and Tobias & Yeh (2009)

Causes of deaths Nolte & McKee (2008) Tobias & Yeh (2009)

Diseases of the

circulatory systemRheumatic heart diseases <45

Ischemic heart diseases – 50% of deaths

Cerebrovascular diseases

Hypertensive diseases

Rheumatic heart diseases

Ischemic heart diseases - 50% of deaths

Cerebrovascular diseases – 50% of

deaths

Diseases of the

genitor-urinary

system

Nephritis and nephrosis

Benign prostatic hyperplasia

Nephritis and nephrosis

Obstructive uropathy and prostatic

hyperplasia

Diseases of the respiratory system

All respiratory diseases (excl.

pneumonia/influenza) . 1-14

Pneumonia/influenza

Chronic Obstructive Pulmonary disease

>45

Asthma < 45

Diseases of the digestive system

Peptic ulcer

Appendicitis

Abdominal hernia

Cholelithiasis and cholecystitis

Peptic ulcer disease

Acute abdomen, appendicitis, intestinal

obstruction, cholecystitis / lithiasis,

pancreatitis, hernia

Perinatal mortality Maternal deaths

Perinatal deaths (excluding stillbirths)

Congenital cardiovascular anomalies – 1-14

Birth defect

Complications of the perinatal period

External causes Misadventures to patients during surgical

and medical care

Results (Tobias & Yeh)

Amenable Mortality all causes, both males and females.

SMR per 100,000 people, 1996 to 2006

0

50

100

150

200

250

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

AUS AUT BEL CAN CZE DEU DNK ESP FIN FRA

GBR GRC HUN IRL ISL ITA JPN KOR LUX MEX

NLD NOR NZL POL PRT SVK SWE USA

0 20 40 60 80 100 120 140 160 180 200

JPN

FRA

ITA

GRC

ISL

SWE

LUX

ESP

KOR

AUS

NOR

AUT

NLD

CAN

DEU

IRL

FIN

GBR

DNK

NZL

PRT

USA

CZE

POL

SVK

MEX

HUN

Amenable mortality - 2006 or last entry

Nolte List - 2006 or last entry Tobias List - 2006 or last entry

Reduction in Amenable mortality between 1996

and 2006 (or last available year)

0 5 10 15 20 25 30 35 40 45

MEX

USA

ESP

PRT

CAN

HUN

POL

FRA

SVK

JPN

SWE

LUX

KOR

GRC

NZL

AUS

NOR

AUT

DEU

GBR

NLD

ITA

DNK

ISL

CZE

FIN

IRL

% Reduction in amenable mortality

Nolte list

Tobias list

0

20

40

60

80

100

120

140

160

180

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

AUS AUT BEL CAN CZE DEU DNK ESP FIN FRA

GBR GRC HUN IRL ISL ITA JPN KOR LUX MEX

NLD NOR NZL POL PRT SVK SWE USA

Results by gender

Amenable Mortality all causes

(Tobias & Yen)

SMR per 100,000 people, 1996 to

2006

0

50

100

150

200

250

300

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Males

0

20

40

60

80

100

120

140

160

180

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Females

0

20

40

60

80

100

120

140

160

180

200

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

AUS AUT BEL CAN CZE DEU DNK ESP FIN FRA

GBR GRC HUN IRL ISL ITA JPN KOR LUX MEX

NLD NOR NZL POL PRT SVK SWE USA

Results, by disease category

Amenable Mortality all causes

SMR per 100,000 people, 1996

to 2006

Transmissible

0

5

10

15

20

25

30

35

40

45

50

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Non transmissible

0

20

40

60

80

100

120

140

160

180

200

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Main findings

• Clear declining tendency in amenable mortality.

• Differences among best performing countries have drastically decreased in

the last ten year.

• France, Japan, Sweden and Island have constantly demonstrated better

results throughout the last decade.

• Eastern European countries and Mexico have systematically performed less

good than the rest of OECD counties.

• US is performing significantly below the rest of OECD countries excluding

Mexico and Eastern Europe.

– Surpassed by counties like Finland, New Zealand, Great Britain, Ireland and

Denmark that were experiencing higher Amenable Mortality in 1996

– No general trend of reduction on Amenable Mortality was identified in the US

since 1999 (except for non-transmissible diseases).

• New Zealand, Denmark and Great Britain have also experienced a constant

decrease in amenable mortality, yet a gap between them and the rest of

best performing OECD countries persist.

Limitations• Dissimilar diagnostic practices of death certification and use of ICD

codes across countries.

• Definition of the causes of death that can be considered amenable

to health care is expected to vary over time

• Definition of age limits is expected to vary over time

• By definition, AM does not take into account:

– Improvements in survival that do not allow people to go beyond 75 years

(AIDS/VIH?)

– Improvements in the quality of life: Is not an appropriate indicator to assess

the performances of health care services, whose primary intend is to

improve the quality of life, with low impact on mortality. E.g.: Mental care

is virtually not taken into account

• Lists of causes of deaths amenable to health care have been

modest in taking into account deaths that could be avoided from

changes in life-styles (abusive consumption of tobacco or alcohol)

Comparisons with other outcome indicators

• Life-expectancy

– Takes into account all causes of death

• Potential years of life lost

– Include all causes of mortality, including external causes (road

accidents, suicide, falls, etc…)

– Age limit: 70 years (for all causes)

– Is the some of all years lost between age of death and 70 years

(death at 50 « weights » half less than death at 30, which is not

the case in amenable mortality).

Life expectancy and amenable mortality

AUSAUT

BEL

CAN

CZE

DNKFIN

FRA

DEU

GRC

HUN

ISL

IRL

ITAJPN

KOR LUX

MEX

NLD

NZL

NOR

POL

PRT

SVK

ESPSWE

UK

USA

y = -12.502x + 1075.4

0

20

40

60

80

100

120

140

160

180

200

70 72 74 76 78 80 82 84

Am

en

ab

le m

or

tali

ty (

20

06

or

la

st

en

try

)

Life Expectancy (2006 or last entry)

Amenable mortality contributes to general mortality by 10% (France) to 18% (Mexico, Hungary)

PYLL and amenable mortality

AUSAUTCAN

CZE

DNK

FIN

FRA

DEU

GRC

HUN

ISL

IRL

ITA

JPN

KORLUX

MEX

NLD

NZLNOR

POL

PRT

SVK

ESPSWE

UKUSA

y = 0.0251x - 7.2491

0

20

40

60

80

100

120

140

160

180

200

0 1000 2000 3000 4000 5000 6000 7000 8000

Am

en

ab

le m

or

tali

ty (

20

06

or

la

st

en

try

)

PYLL (2006 or last entry)

Conclusions

• Amenable Mortality is a practical and effective indicator that could

be useful in the comparison of the performance of health care

systems across OECD countries.

• AM offers the potential to go further in the identification potential

weaknesses of health systems (by categories of diseases)

• Inclusion in OECD health data requires the choice of a list

• AM is only an indicator of outcome. It should be related to resources

invested in health care to really assess health systems performance

(efficiency)